Discussion

Chapter 13

Emotion-Focused Therapy

LEARNING OBJECTIVES

By the end of this chapter, you should be able to:

•understand the theoretical underpinnings of emotion-focused therapy,

•understand the central tenets of emotion-focused therapy, and

•apply emotion-focused therapy to individuals and groups.

INTRODUCTION

Successful social work practice deeply relies on the social worker’s emotional intelligence. “The emotionally charged nature of all social work encounters require practitioners to reflect on how the work impacts on them and to draw on the understanding which reflection affords to inform their practice.” Social workers need to be aware of their own and their clients’ emotions and to be able to use them effectively in their practice.

Understanding emotion is important for building a working relationship with the client and for making the most of a given encounter with service users. Client involvement has become a central part of practice; client participation in decision-making, for example, is key to successful outcomes and legally required in Codes of Practice. Interestingly, given the importance of the working relationship with clients, it has been discussed and studied far less in theoretical concepts in the social work literature and there are very few concepts as to how to build a professional relationship and work with it. From psychotherapy and counseling meta-analyses we know that relationship factors account for most of the change within the professional encounter and that the techniques used by the social worker do not account for more than the expectations clients have. The same pattern could be shown for all stages in casework practice in social work, where the success of assessment and intervention relied on the awareness and management of emotions. Emotional literacy and empathy skills, however, are needed to form professional relationships.

Social work practice often deals with clients in very difficult life situations, which involve powerful emotions such as shame, depression, and hopelessness. Moreover, social workers have to be able to tolerate and work with uncertainty, both with their clients and within themselves. As Ruch et al. (2010) state, “The bread and butter of social work is emotionally charged” (p. 17).

Emotional intelligence is important not only for an effective social work practice but also for social workers themselves and their own health and well-being. Compassion fatigue, vicarious trauma, and secondary traumatic stress have been described as specific risk factors for practitioners, and burnout and impaired emotional health are major health problems among social workers. One of the major symptoms of burnout is emotional exhaustion, described as emotional numbness and the inability to relate to the client in a person-to-person way. Building a working relationship with the client, however, lies at the heart of social work practice in almost all fields of direct practice, however short the client contact may be. Emotional health, therefore, is as important for social workers as it is for their clients.

In summary, a number of aspects of social work require an emotional literacy that social workers need to develop not only through everyday practice and experience but also through systematic analysis and training in how to best understand and work with emotions. Social workers need “permission, but also consideration of developing a language of emotion” (Ingram, 2013, p. 1001) and as Ingram further suggests: “It may be that social work can draw from literature relating to counselling and psychotherapy to support developments in this area” (p. 1001). Emotion-focused therapy offers a theoretically grounded and empirically tested framework for working with emotions in counseling and psychotherapy. It has been developed, practiced, and evaluated over the past 30 years within a variety of client groups and settings (Greenberg, 2014). Emotion-focused therapy can be understood as “the practice of therapy informed by an understanding of the role of emotion in psychotherapeutic change” (Greenberg, 2011, p. 3). The main goal is strengthening the self by helping the client to attend to their emotional experience and to create new meanings that will eventually alter their being in the world. Thus, the emotionally intelligent social worker (Howe, 2008) facilitates and directly works with the client’s emotional processes. Emotion-focused therapy is an integrative approach that builds on various influences from both neuroscience and humanistic traditions within psychotherapy and counseling.

OVERVIEW OF EMOTION-FOCUSED THERAPY

Understanding of Human Problems

According to the humanistic and experiential perspective, people have all the resources to understand and solve their problems. They are biologically wired to move forward, grow, and make sense of their experiences. People have a tendency to self-actualize; through this self-actualization, a healthy person becomes free from inner tension, becomes aware of their emotions and reactions, and makes better choices in life.

Human problems are viewed to have “biological, emotional, cognitive, motivational, behavioral, physiological, social, and cultural sources” (Greenberg, 2014, p. 18). Emotions, however, are understood as the key processes that orient people in the world and help them evaluate whether a current situation meets their needs or not. Accordingly, “changing emotions is seen as central to the origins and treatment of human problems” (Greenberg, 2014, p. 18).

Our ability to feel has survival value for us as a species but also for us individually. Emotions are our resources to understand our personal lives; they connect our past and future and show us what we are drawn to and why. Our gut feeling is shaped by our past experiences as we see patterns and draw conclusions on an emotional level much faster than our thought and problem-solving processes can ensure. Emotional reactions thus can be understood as an economic and fast way to understand a situation. The complexity of human interaction is reduced to a decision about whether the situation in question is potentially threatening or rewarding. Therefore, even when people are not very good at distinguishing their emotional reactions, they can still say whether something felt good or bad. Asking them what exactly they felt, they may not be able to label their emotions beyond what is called valence—good or bad. Thus, we understand our emotions as our primary system that has survival value.

Moreover, emotions can only be understood in context. Feeling and display rules are culturally shaped, and meaning-making processes are deeply embedded in a person’s life history and are culturally framed. In order to make informed choices and develop a systematic professional way of working with our clients, we need to integrate feeling and thinking in a way that is termed “reflective practice.” People often misunderstand the process of reflection as a process of thinking about their emotional reactions and making sense of them with regard to their personal histories as well as situational factors. Thinking about emotion, however, is limited as these two processes often do not go hand in hand. We may have emotions we do not understand intellectually, or we try to talk ourselves out of an emotional state, for instance by convincing ourselves that there is no need to be afraid and worried. In most cases, the worry and anxiety will not simply disappear when we debate whether or not they are rational. Emotions do follow their own logic and thinking about them often does not alter them. What we can think about and change are our reactions to our emotions, the way we show them to others or suppress them. Thus, by thinking about our emotional reactions, we may only tap into these cultural undercurrents of emotional feeling and display rules. We also know from research in social psychology that situational factors define what emotions we feel much more than our personality traits and personal past. Thus, understanding emotions as key to human problems as well as a route to overcome them fits very well into a person-in-environment perspective in social work. Emotions, by definition, integrate biology and culture (Edwards, 1999).

From an emotion-focused perspective, we distinguish two problems clients can have related to emotional processes. One possibility is that clients can be overwhelmed by their emotions so that they cannot use the information embedded in the process, which is called an underregulated process. If emotions become too overwhelming, for example, clients can enter dissociative states in which they no longer have access to their emotions. Clients with a diagnosis of borderline personality disorder, for example, experience states of inner tension and stress that may become so overwhelming that they try to stop these states by hurting themselves. Learning to distinguish and regulate emotions, therefore, is an important goal when working with these clients. Another example of underregulated processes can be seen in violent youth—here, often emotions of anger are so overwhelming that people become aggressive. Interestingly, when working with these people, it often becomes clear that they have difficulties distinguishing social cues and experience provoking or threatening social signs in their environment more often than others. Here, the underlying pattern has to be understood and changed so that people learn to better distinguish social cues and nonverbal signs as threatening or neutral. Again, it becomes clear that working on an emotional level in order to understand clients’ emotional reactions integrates inner resources and interpersonal social factors.

On the other hand, clients can be emotionally distant such that they feel too little emotion and cannot make sense of their emotions. For example, clients sometimes develop psychosomatic symptoms like headaches and feel pain in their bodies rather than their emotional pain. This process is called an overregulated process. Overregulation often occurs when clients do not give themselves permission to feel or label their feelings as silly and inappropriate. For example, many depressed clients have difficulties experiencing anger and view anger as potentially threatening their social bonds and relationships. In some cases, they may have experienced a violent home and do not have a social role model of expressing anger in a nonviolent way—experiencing anger then is often viewed as potentially harmful to others and suppressed.

Recent clinical research has shown that problems in emotion regulation are a key element in understanding how people develop symptoms and clinical disorders (e.g., depression and anxiety). Healthy functioning involves a rich emotional life as well as “being flexible” (Bonanno et al., 2004), which involves people having the ability to express as well as suppress emotions. Greenberg (2014) lists four major difficulties in emotional processing: (a) lack of awareness, (b) maladaptive emotional responses, (c) emotion dysregulation, and (d) problems in emotion/narrative construction and existential meaning. Emotion-focused therapy is designed to help people find a productive distance from their emotional experiences in order to make sense of them, use them, and be guided by them through a self-actualizing process toward better health, healthier relationships, and better decisions in life.

Conception of Therapeutic Intervention

According to the humanistic tradition, emotion-focused therapy views people as experts of their personal lives and the choices they make. Clients are seen as “active self-healers” (Bohart, 2006), making use of therapy and counseling in their own individual way. Developing, regaining, and strengthening a person’s agency, thus, is a key element and therapeutic task in emotion-focused therapy. In Gendlin’s (1984) tradition of “giving therapy away,” the therapist in emotion-focused therapy is seen as an emotion coach, helping clients access productive emotional processes that will eventually help them deal with and overcome their problems within their own time. “EFT [Emotion-focused therapy] proposes that emotions themselves have an innately adaptive potential that if activated can help clients reclaim unwanted experience, change problematic emotional states, and change interactions” (Greenberg, 2014, p. 17).

In their article “The Essence of Process-Experiential/Emotion-Focused Therapy,” Elliott and Greenberg (2007) list five central features of this approach: “neo-humanistic values, process-experiential emotion theory, person-centered but process-guiding relational stance, therapist exploratory response style, and marker-guided task strategy” (p. 241). In emotion-focused therapy, a person-centered, empathic, professional relationship is the basis for therapeutic work on emotion. According to Greenberg (2014), these are the two treatment principles: the relationship and direct therapeutic work on client emotional processes.

Empathy, positive regard, and congruence, as originally described by Rogers (1957), are key elements in building the helping relationship in emotion-focused therapy. Empathy is understood as the therapist’s ability to understand the client’s emotions and needs, as well as “a process of coconstructing symbols for experience” (Bohart & Greenberg, 1997, p. 6). Empathy thus develops moment by moment in the actual therapist–client interaction.

Positive regard is expressed through praising of the client—regardless of the client’s life circumstances, behavior, or choices—simply for who they are. It involves a positive and optimistic outlook on the client’s life and possibilities, and is closely related to humanistic values. It involves accepting personal choice and freedom and a basic trust in the client’s self-actualizing tendency, resilience, and ability to develop and grow.

Congruence, on the other hand, is related to the therapist’s or counselor’s own integrity and maturity,

and is the basis for a dialogical person-to-person encounter. More recently, this aspect has been developed further to integrate mindfulness approaches in order for the therapist to become more fully aware of the moment-to-moment process and more present in the actual moment (Greenberg & Geller, 2011). The therapist’s mindfulness and presence are positively related to the client’s improvement in interpersonal difficulties (Ryan et al., 2012) so that “therapist dispositional mindfulness may be an important pre-treatment variable in psychotherapy outcome” (p. 289). The two aspects of mindfulness—”act with awareness” and “accept without judgment”—proved most important for this outcome.

Mindfulness can help the therapist to develop and use their own congruence; however, it has also become a specific tradition in psychotherapy on its own accord. Gaynor (2019), for example, developed emotion-focused mindfulness therapy (EFMT), introducing mindfulness-based interventions into the therapy protocol. There is, however, an interesting distinction between the concept of mindfulness and awareness of emotion. Awareness is reached by staying with a feeling, whereas mindfulness is understood and reached by letting it pass without changing or judging it. Most exercises in mindfulness, above all meditation, try to help people focus on the current moment without judgment and letting it pass into the next moment. Awareness exercises—most of which have been developed in the tradition of gestalt therapy—help people stay and heighten a specific emotional reaction in order to fully experience and thereby understand it. For example, if a client talks about an event and unknowingly punches the armrest of their chair, their awareness may be guided toward that movement and they may be asked to focus on it and do it some more and observe their emotional reaction while doing it. The bodily movement has already carried the underlying emotion—for example, anger; however, the client may not have been aware of this emotion. By helping the client focus on their bodily movements accompanying the conversation, the therapist may help the client to become aware of it. Awareness thus is linked to having an insight, which always integrates feeling and thinking, whereas mindfulness at its best lets go off thinking and is pure being in the moment—moment by moment.

In addition to these core conditions—positive regard and congruence, and an empathic attunement–the emotion-focused therapist has to ensure collaboration on the goals and tasks of therapy. The goal is task completion, empowerment, and integration of emotional processes that will eventually lead to more self-acceptance and a more resilient self. This goal is reached by working together on specific processing tasks that the therapist suggests to the client. Therefore, the therapist assesses the client process and listens for process markers. A process marker can be the client’s voice (too distant from an experiencing voice, e.g., a lecturing voice), specific words that show a self-critical process (e.g., “I am a failure”), a specific posture that shows a collapsed helpless and hopeless self, or direct emotional expression like anger or hurt.

Emotion-focused therapy integrates various forms of working with emotion into a coherent frame. Five empirically based principles of working with emotion have been found: focusing, accepting, and allowing emotions (awareness); working with under- and overregulated emotional processes (regulation); facilitating emotional expression over suppression (expression); changing emotion by emotion (transformation); and symbolizing and reflecting emotion (reflection; Greenberg & Pascual-Leone, 2006). More recently, working with client narrative processes to promote and integrate emotional change (Angus & Greenberg, 2011) and forms of corrective emotional experiences (Castonguay & Hill, 2012) have been added as general strategies of working with emotion.

Specific strategies for working with emotions are related to in-session markers of client processes that are differentiated by the therapist. These strategies will be described more fully using a case example. In summary, emotion-focused therapy uses a process-guided approach with a special focus on microprocesses as they unfold in the session.

HISTORICAL DEVELOPMENT

Precursors

Emotion-focused therapy is based on a humanistic understanding of problems and interventions. As it applies to a person-centered way of relating to clients, its origins can be traced back to Carl Rogers’s (1957) work on defining a helping relationship.

Later, Laura Rice (1974), a student of Rogers, added the “evocative function of the therapist” to client-centered therapy. Her studies of the therapy process moment-by-moment revealed that therapist interventions could deepen clients’ emotional processing. Rice especially studied client vocal quality and how it shifted from external to internal when the client focused inward. Thereby, the first process measures for studying the client’s change process were developed and tested (Watson & Wiseman, 2010). The focus then naturally shifted to the therapist and client–therapist interaction, asking how the client process could be best facilitated by therapist actions. At that time, Les Greenberg became a student of Laura Rice, and their idea was to develop a map of the exact steps clients go through in order for a change process to be successful.

Greenberg also worked closely with developmental psychologist Juan Pascual-Leone, who had studied with Piaget. Together they developed the model of a dialectical-constructivist understanding of the change process and an understanding and analysis of tasks that the client solves in session. A task refers to a specific cognitive emotional process (e.g., self-soothing), differentiating and integrating inner voices, solving decisional conflicts, or mourning a loss. As the main therapeutic focus was following and leading the client through the stages of emotional processes, the therapy was first (and sometimes still is) called process-experiential psychotherapy. Greenberg et al. (1993) published a manual that focused on therapists’ actions of facilitating emotional change processes moment by moment. As more and more studies revealed that the core change process was related to changing core emotional schemes, the therapy was renamed emotion-focused therapy. Moreover, an increasing number of results from affective neuroscience provided a rationale for directly working with emotion and supported the notion that emotional change lies at the heart of all human functioning, such as thought processes, motivation, and action.

The therapy sometimes is also known as process-experiential emotion-focused therapy (PE-EFT). Reconciling inner voices in conflict had been developed out of working with the couples system where real-life conflicts were acted out between two people. Developing emotion-focused therapy, therefore, was also influenced by systemic thinking and an existentialist understanding of human beings and their being in the world. As experiencing and affect are given priority over intellect and thinking, influences of gestalt therapy (Perls, 1969; Shorkey & Uebel, 2008) and the use of imagination played a crucial part in developing emotion-focused therapy. In fact, the two-chair technique and a dialogical gestalt therapy (Jacobs & Hycner, 2010) still have some similarities in how the client process is understood and utilized.

Later Developments and Current Status

Extensive work with various client populations and problems led to the development of specific approaches for specific clients. At first, emotion-focused therapy was developed and applied to clients with depressive symptoms. Two large research projects at York University in Toronto, Canada, provided the background and funding for developing emotion-focused therapy for depression (Greenberg & Watson, 2006). Specific tasks, like differentiating and integrating critical voices, were developed and evaluated in the course of these projects.

In 2010, Sandra Paivio and Antonio Pascual-Leone published the manual for emotion-focused therapy for complex trauma. It grew out of 20 years of experience working with survivors of child abuse in which a modified version of chair work was developed and widely empirically tested. This technique is called imaginal confrontation and lies at the heart of emotion-focused therapy for complex trauma. In short, in an imaginal confrontation, the client is guided through a dialogue with the imagined perpetrator in an empty chair. By guiding the client through the process in a stepwise procedure, the trauma can be integrated and healed.

Emotion-focused therapy has been developing and growing rapidly in various directions; one is further differentiation of the approach for specific client groups. Eating disorders have been successfully treated using a modified approach called emotion-focused family therapy (EFFT; Dolhanty & Greenberg, 2009). Furthermore, specific tasks for anxiety disorders have been developed, for example, enhancing clients’ ability to self-soothe (Elliott, 2013). Watson and Greenberg (2017) have recently compiled a handbook for working with clients with generalized anxiety disorder in an emotion-focused way. Integrating emotion-focused therapy with cognitive behavioral therapy has been successful for clients with anxiety disorders in a randomized controlled trial (Newman et al., 2011). In a similar way, a modified form of using chair work for clients with a diagnosis of borderline personality disorder has been proposed to meet the needs of this client group (Pos & Greenberg, 2012). Finally, emotion-focused couples therapy has been further developed (Greenberg & Goldman, 2008) to directly work with power relations within a couple’s system in addition to their attachment needs. Another form of couples therapy had been developed earlier by Sue Johnson, which stressed the importance of attachment as the basis for a healthy and long-lasting relationship (Johnson, 2002). Greenberg and Woldarsky-Meneses (2019) offer insight into the specific processes of forgiving and letting go in emotion-focused therapy regarding individuals and couples. Finally, Greenberg and Goldman (2018) edited a clinical handbook of emotion-focused therapy that can be seen as the most recent source of the modifications and the evidence of working successfully with various client groups.

To date, there are very few examples of emotion-focused therapy for children and youth. A form of EFFT has been developed to work successfully with children and youth with eating disorders and their families (Dolhanty & Greenberg, 2009; Robinson et al., 2013). The EFFT model has now been outlined in a clinical manual by Lafrance et al. (2019).

Therapists, however, do not only need specific skills for clients with specific problems and needs but also more general skills for working with emotion in the session. One major skill for therapists to learn and practice is their own mindfulness and presence (Greenberg & Geller, 2011). By developing mindfulness, therapists and counselors not only enhance their practice and effectiveness with service users, they also maintain and enhance their own well-being.

As emotion is understood as the key component in client change, in the future all therapeutic approaches should integrate knowledge of emotional change processes and therapists’ and counselors’ skills in how to best facilitate them. Greenberg (2011) states:

The term emotion-focused therapy will, I believe, be used in the future, in its integrative sense, to characterize all therapies that are emotion-focused, be they psychodynamic, cognitive-behavioral, systemic, or humanistic. … What will distinguish and differentiate an approach as emotion-focused will be its emphasis on the importance of affect in human functioning and on the experience of emotion in sessions. (pp. 141–142)

Past and Current Connections to Social Work

Social work practice can be understood as emotion work that continuously needs supervision and reflection. Not surprisingly, working with the self has been an area of training of social workers as reflective practice is central in social work practice (Ruch, 2005). Self-knowledge and self-awareness are crucial in working effectively with service users. However, “it is probably more common than we might imagine for social workers and others to feel unable to really see other’s pain and distress” (Ward, 2010, p. 50). Understanding emotions and being aware of them, therefore, has been introduced as the concept of the “emotionally intelligent social worker” (Howe, 2008).

Moreover, understanding the discipline according to its current definition as “a practice-based profession and an academic discipline that promotes social change and development, social cohesion, and the empowerment and liberation of people” (https://www.ifsw.org/what-is-social-work/global-definition-of-social-work/), both social work practice and emotion-focused work are based on humanistic values and ethics. In fact, emotion-focused therapy fully acknowledges peoples’ choices and their ability to grow and develop. The goal of emotion-focused therapy can be seen as empowering and liberating people from inner voices that undermine a person’s resilience and their capacity to grow. As the therapeutic relationship is key for a person’s empowerment and change process, emotion-focused therapy can be well understood and integrated into the current turn to “relationship-based social work” (Ruch et al., 2010). This implies an understanding of service users not as rational but as relational beings. “Reconceptualising the practitioner means acknowledging their emotional responses and the emotional impact of practice on them” (Ruch et al., 2010, p. 27).

CENTRAL THEORETICAL CONSTRUCTS

Emotion-focused therapy has been described as “a treatment that is neohumanistic, process oriented, and emotion focused” (Greenberg, 2011, p. 13). Accordingly, the central theoretical constructs are neohumanistic concepts, such as the understanding of the self, self-actualization, and experiencing theory (Greenberg & Van Balen, 1998). The process orientation is grounded in dialectical constructivism, and the focusing of emotions is based on emotion theory and affective neuroscience. Moreover, emotion-focused therapy draws upon clinical research, focusing, and attachment theory. It can thus be seen as an integrative approach. As Elliott (2012) states:

In an era of increasing demands for brief, effective treatments and criticism of humanistic/experiential psychotherapies (HEPs) for lack of theory and empirical support, Emotionally-Focused Therapy appears to offer a viable development of the humanistic and person-centred traditions, while at the same time appealing to therapists from other traditions. (p. 108)

Within the humanistic tradition, experiencing theory posits that people have an ongoing inner process of experiencing that they can attend to at any moment.

Thus, the process orientation of emotion-focused therapy relies on this moment-to-moment process of experiencing. Therapist relational conditions of accurate empathy, unconditional positive regard, and genuineness are seen as the core constructs within the therapeutic relationship that help clients to attend to their inner processes of experiencing. The self-actualizing tendency posits that this inner process of experiencing is geared toward self-actualization. Experience is continuously symbolized within the self. However, people are not aware of all their experiences in a given moment, leading to incongruence between the self and experience. This incongruence is experienced as inner tension within the person.

According to the humanistic tradition, people will be able to reduce their incongruence by becoming increasingly aware of their experiencing process and attending to their inner processes with a nonjudgmental, curious, and open attitude. They internalize the relationship characterized by accurate empathy, unconditional positive regard, and genuineness experienced in the therapist–client relationship so that they themselves can be more open toward their experiences, symbolize, and integrate them.

It is not any one configuration within the client’s Self which is important but the whole constellation of configurations and the dynamics which define their interrelationships. It is this dynamic integration which will result in an overall picture that reflects the person’s Self. (Mearns & Thorne, 2000, p. 114)

The “fully functioning person,” according to Rogers (1961), will be able to flexibly experience feelings in the moment and use them to make better decisions that are more in accordance with their inner life. Thus, incongruence is the core process of a person’s pathology and will be reduced mainly by integrating formerly not symbolized aspects of the person’s individual experiencing process. The most important therapeutic tool is the therapeutic relationship and the client’s process of self-exploration, symbolizing, and meaning-making.

In emotion-focused therapy, these humanistic constructs have been described in terms of emotional processes and dialectical constructivist ideas. Dialectical constructivist theory posits that experiencing and meaning-making are in dialectic tension. “One therefore continually creates as well as discovers who one is” (Greenberg & van Balen, 1998, p. 39). Experience is organized and activated in emotion schemes, which basically operate in two different ways. New experience is either continuously integrated in existing schemes by a process of assimilation, or if new experience cannot be integrated, a new scheme emerges as the result of a process of accommodation. These processes have been described by developmental psychologist Jean Piaget (1952) and applied by Greenberg and neo-Piagetian Juan Pascual-Leone (1995, 2001, 2006) to understand emotional schemes and processes.

When, for example, the components of a conflict are activated in therapy, the two opposing processes interact, and a new, higher level structure may be spontaneously synthesized. … This new structure captures within itself the pattern of co-activation of the previously opposing schemes, as well as newly formulates material, thus forming a higher level structural totality. (Greenberg & Pascual-Leone, 1995, p. 180)

Thus, focusing emotion in therapy helps integrate experience into existing emotion schemes or create new, more adaptive, and healthier emotion schemes. For example, in the treatment of depression, a helplessness and hopelessness scheme coactivated with a process of anger will eventually result in the depressed person’s empowerment. In this way, anger undoes hopelessness, leading to a healthier and more resilient configuration within the self (Greenberg & Watson, 2006). The change process is also facilitated by positive emotions that clients feel in their relationship with their helpers.

Emotion-focused therapy stresses that people solve cognitive-affective tasks in therapy; as a result, healthier emotion schemes emerge. The client–therapist relationship is the most important tool in therapy. Additionally, chair work has been introduced to directly activate emotion schemes and work with clients’ core maladaptive emotion schemes that continuously lead to specific symptoms. For example, a depressed client may experience depressive hopelessness that stems from the client’s core scheme of shame and guilt. Critical inner processes constantly activate the inner shame that is experienced as depression. In emotion-focused therapy, these maladaptive processes are activated and worked with, mainly by coactivating and synthesizing opposing processes in a guided intervention like two-chair work.

PHASES OF HELPING

The phases of helping in emotion-focused therapy are empathic attunement, as a way of engagement with the client; focus on emotion, which corresponds to data collection and assessment; activation of maladaptive emotion scheme and reflection and work with client narrative, as ways of intervention; and finally, termination of therapy.

As the therapeutic relationship is given priority over technical aspects of accessing and transforming emotion, establishing a good relationship with the client who can act as a secure base for further emotion work is essential. Although establishing a relationship is central for the beginning of therapy and the first sessions, the therapy process will often demand work on the relationship, for example, in an alliance rupture where the relationship is the focus rather than the background for other emotion work. As emotion-focused therapy is process oriented, the phases of therapy are not linear and aspects of building a relationship, assessing emotion, focusing on emotion, and ending a specific task in therapy are circular and can become the focus at any time in therapy.

Still, there is a structure that therapy can be expected to follow in a general sense and it is useful to briefly summarize this before introducing the main phases of helping in more detail. In the first five sessions of a short-term emotion-focused therapy of about 16 sessions, as the therapeutic relationship develops, therapist and client begin to focus on emotion, heighten emotional awareness, and try to understand the core emotion scheme that lies at the heart of the client’s problems. Once the core scheme has been activated, usually in the middle of therapy, by, for example, repeatedly using different chair dialogs, new emotional experience will be used within the session to change the core scheme. The therapist follows the client process and makes suggestions for processing emotion further. For example, the therapist may help the client to confront a critical part of themselves with a two-chair dialog or to become angry with an abusive partner or parent in an empty chair, if there are signs indicating that these are the relevant processes. The therapist, thus, is an “emotion coach” (Greenberg, 2002), following as well as leading the client in their individual emotional process.

Experiencing new emotion is naturally followed by the client reflecting on their experience. The basic therapeutic process within a typical session in emotion-focused therapy can be described as alternating between the client’s experiencing facilitated by chair work and reflecting on their emotional experiences. Ideally, individual sessions as well as the entire therapy process intensify the depth of experiencing in the middle section and move to lower experiencing and more narrative elements of meaning making toward the end. At the end of therapy, a new client narrative emerges. In successful therapies, the client views themselves as more resilient and empowered. The previous maladaptive core emotion scheme is transformed and replaced by a new one that reorganizes the person and their being in the world in a new way. A new narrative of their life emerges.

Engagement: Empathic Attunement

First, an empathic therapist–client relationship is established as it is the basis for the client and therapist to focus on emotion. In emotion-focused therapy theory, relationship and task principles have been described (Elliott et al., 2004). Clients need to feel safe and understood within the therapist–client relationship before deeper work on emotion schemes can be initiated. Here, the focus on emotion and empathic attunement blend together imperceptibly. Right from the beginning of therapy, the therapist pays attention to where the affect is most salient in the narrative the client presents. An emotion-focused therapist thus attends to emotion signals from the very beginning of therapy. Emotion signals can refer to facial expressions, emotion words, pauses, voice quality, or expression of emotions such as trembling of hands or tears. A focused voice is a signal of the client attending to an inner process and focusing inward. From the beginning of the therapeutic encounter, therapists assess how easily this can be achieved or whether the client narrative is very distant and factual.

Data Collection and Assessment: Focus on Emotion

Emotion-focused therapy case formulation centers around the core maladaptive emotion scheme, which has to be activated and understood (Goldman & Greenberg, 2014; Watson, 2010). Often the story and symptoms the client presents with are secondary to the core process. For example, a student presented with acute anxiety and on a behavioral level procrastinated and found himself in a difficult situation where he was confronted with the possibility of being expelled from his studies. On a deeper emotional level, his anxiety was driven by shame and insecurity about having chosen the wrong career and thus represents the result of a self-critical process. In emotion-focused therapy, the therapist wants to address and change the determinants of maladaptive emotions, cognitions, and behavior.

Emotion-focused therapy is a transdiagnostic treatment; a formal diagnosis of a given psychopathology is no indication for applying this approach. Rather, the client’s ability to focus on emotion is important to use the therapy effectively.

Assessing emotion types and regulation strategies is essential for applying the emotion-focused therapy protocol. Emotion types can be differentiated according to their usefulness within the course of therapy; for example, as productive emotional processing if they further the process or unproductive emotional processing if they leave the person feeling stuck or overwhelmed. In order to use the information an emotion conveys, emotions cannot be experienced in an overwhelming manner, nor in a too distant manner. A working distance to one’s own emotional experiencing is needed that varies from person to person.

The therapist has to judge continuously how the client experiences emotion—whether the emotion is overwhelming, meaning the emotion is undercontrolled, or whether the emotion is too distant and overcontrolled, which means that it is not felt in the moment and used. Both types of processing should be worked with for clients to achieve a working distance that enables them to feel, express, label, understand, and use their emotions. Accordingly, some clients need help with their emotional processing abilities to control their emotions when they are overwhelming, whereas others need help to enhance their emotional experiencing if they overcontrol emotional experiences or avoid and fear their feelings. Emotion-focused therapy has been compared to training in emotional intelligence. Greenberg (2002) states:

Emotional intelligence thus involves the ability to identify emotions in one’s own physical states and in others and the ability to accurately express emotions and the needs related to these emotions, as well as being able to discriminate expressions in others. (pp. 58–59)

Before emotion schemes can be focused on by applying various forms of chair work in the session, the client has to develop emotion regulation strategies. Assessing clients’ capacities to regulate their emotions is an essential part of the process diagnosis in emotion-focused therapy. For some clients, developing emotion regulation strategies requires another therapy that they need to complete before they can enter emotion-focused therapy. Clients with borderline personality disorder, for example, first have to learn emotion regulation strategies in dialectical behavioral therapy before they can directly work with their emotions in emotion-focused therapy. For clients with a diagnosis of generalized anxiety disorder, cognitive behavioral therapy can be integrated with emotion-focused therapy. Cognitive behavioral therapy can be used to address and manage client anxiety in the beginning part of the session before more emotion and relationship work can be used in the second part of the session (Newman et al., 2011).

Intervention: Activate Maladaptive Emotion Scheme and Work With Client Narrative

Before emotional tasks can be focused on in emotion-focused therapy, the therapist has to build an alliance with the client and get an agreement from them about focusing on emotion and working with emotion in this way. This is based on Bordin’s understanding of the alliance, which encompasses a positive affective bond between client and therapist, as well as consensus about the goals of therapy and the means by which these goals can be reached (Bordin, as cited in Horvath & Bedi [2002]). Goal consensus and task collaboration are as important as the affective bond between client and therapist.

A task in emotion-focused therapy is a specific cognitive-affective process required by the client in order for them to go forward in therapy. For example, if the client experiences an emotion and does not know why, the task is to understand this emotion through a process of self-exploration that is facilitated by the therapist through a technique of empathic evocative unfolding. The therapist not only follows the client in their narrative and experiencing but also deepens the processing, for example, by using metaphors. An unclear felt sense can become clear when the right metaphor or word is found; sometimes this can be suggested by the therapist. In this task, the therapist helps the client focus and explore emotions by using specific empathic responses.

Another task is a self-critical process in which two sides within the client are in opposition. Here, the client needs to fully express both parts and their underlying needs in order to integrate them into a new emotion scheme. The therapist facilitates this process by suggesting a two-chair dialog once the two parts have become clear. As each part has its own emotions, typical sequences of emotions have been found that help the client complete this task. For example, secondary emotions of helplessness will first occur when the critical part attacks and criticizes the self in the experiencing chair and clients often first agree with the critic. Emotionally, the self will either collapse or fight back. Letting the emotions emerge naturally rather than pulling for them is important and requires specific therapist training and experience.

In successful therapies, eventually the self is empowered, and the client can acknowledge and express their needs and will start negotiating needs with the critical part of the self. An integration of both needs and parts will occur rather than the critical part fully withdrawing. Often there is worry or anxiety that drives the critical part, which has to be acknowledged and worked with.

In emotion-focused therapy, the therapist constantly makes diagnoses of the moment-to-moment process and emotional processing suggestions for the client. The therapist has to follow the client process empathically, while guiding the client toward tasks and task completion. Greenberg (2002) states: “The coach is like a guide who knows paths through the emotional terrain and the client the explorer who sets the goals, decides on the pace, and is in control of the expedition” (p. 80). The therapist has to listen for markers of client processes, recognize tasks, and make appropriate emotional processing suggestions. Marker-guided interventions are therefore at the core of emotion-focused therapy. A map of up to 10 process markers has been developed and defined to date (Elliott, 2012). Specific marker-guided interventions are embedded in the general strategies of working with emotions in therapy and in the relationship and task principles of emotion-focused therapy (Bischkopf, 2013).

Termination

As the client is seen as the “active client” (Bohart, 2006) in charge of their own process, termination is understood as a process initiated by the client. However, the therapist has to make clear from the beginning of therapy that the therapeutic relationship is temporary and will eventually come to an end.

Preparing the client for ending is an important subtask in emotion-focused therapy, and a few sessions should be reserved for ending work and addressing issues the client feels are important to work on before therapy ends. Ending therapy may be accompanied by feelings of sadness or anxiety about the future for some clients, and by feelings of pride, hope, and optimism by others. Comparing how the client entered therapy to how they leave it is a helpful intervention, especially for anxious clients. Leaving time for evaluating the therapeutic process and good moments in therapy, as well as in the client’s life outside therapy, is an important step in the process of termination. Following the dialogical principle, it may also be relevant for the therapist to disclose their own experience of therapy and their own genuine reaction to ending.

APPLICATION TO FAMILY AND GROUP WORK

An EFFT model has now been outlined in a clinical manual by Lafrance et al. (2019). On the website for EFFT, the approach is described as being able to “afford families a significant role in their loved one’s recovery from an eating disorder, and to empower parents and caregivers with specific skills to be effective in this role” (emotionfocusedfamilytherapy.org). Strategies of emotion coaching and relationship repair are applied using the emotion-focused therapy model. Studies and case descriptions show very promising results (emotionfocusedfamilytherapy.org). Applications of emotion-focused therapy to family and group work have been successful in systematic pilot studies, and EFFT for eating disorders (Robinson et al., 2013) has been developed and is currently being applied and researched. EFFT may be especially powerful for social workers as they are often confronted with families in crises and need of support. Adding emotion-focused perspectives to a more behavioral approach can help them to be more effective, and thanks to these new publications, rich resources are available in order to broaden clinical skills. Moreover, EFFT offers a new framework for understanding individual and family problems and possible new ways of supporting them.

To date, there are only three studies systematically addressing the application of emotion-focused therapy to group work (Pascual-Leone et al., 2011; Robinson et al., 2014; Wnuk et al., 2014). Pascual-Leone et al. (2011) reported positive outcomes for a group of incarcerated men with a history of intimate partner violence. Wnuk et al. (2014) showed a decrease in the frequency of binge episodes, improvements in mood, and improvements in emotion regulation and self-efficacy in 12 women with binge-eating disorders after a 16-week emotion-focused therapy group program. Robinson et al. (2014) collected in a pilot study pre- and postgroup data for individuals suffering from anxiety and depression. Postgroup and follow-up scores in the Difficulties in Emotion Regulation Scale (DERS) were significantly lower than pregroup scores. Although it was a very small sample of only six participants, these results are promising as emotion regulation difficulties are seen in many clinical theories as relevant for developing symptoms and psychopathology.

Participants in the last study also reported what the authors referred to as “vicarious emotional processing and learning while observing others doing chair work” (Robinson et al., 2014, p. 271). One participant, for example, said: “What that person was saying, that’s when I realized, I had those feelings. And it made me go even further into myself” (Robinson et al., 2014, p. 271). Participants also reported using newly found self-soothing strategies, which are especially important for clients overcoming anxiety and depression.

As stated, EFMT developed by Gaynor (2019) is offered in a group format of eight to 12 group sessions and a one-day retreat. The groups consist of approximately eight participants, and monthly group meetings are offered to continue after the actual group has ended. Integrating mindfulness and emotion-focused strategies seems a potentially promising new way for developing group treatments—building on the evidence for mindfulness-based approaches in overcoming stress, depression, and anxiety often offered in a group format (Bohlmeijer et al., 2010).

COMPATIBILITY WITH THE GENERALIST-ECLECTIC FRAMEWORK

Emotion-focused therapy is an integrative approach that stresses the role of the therapeutic relationship and the importance of common factors in achieving therapeutic change. It therefore fits very well into a generalist-eclectic framework.

Approaches for working with emotion can be differentiated in being experiential, coping oriented, or insight oriented. Emotion-focused therapy works directly with the process of experiencing. In contrast, cognitive behavioral approaches focus more on coping with emotions by teaching skills for managing them. In anger management programs, for example, clients learn to better control their anger and express it in a socially acceptable way (Greenberg & Bischkopf, 2007). Insight-oriented approaches to working with emotions focus on the underlying symbolic meaning and help clients understand why they feel a certain way in a given situation and how that informs them about who they are or have become. Which way of working with emotion is most effective depends on the client and the client’s problem. A generalist-eclectic framework allows the therapist to choose the best way of helping the client without having to follow a predefined protocol. Emotions, by definition, integrate biological, cultural, situational, and idiosyncratic aspects of the person in their environment and thus need to be understood, addressed, and worked with in an integrative manner.

CRITIQUE OF THEORY

Strengths

Because of its wide range of outcome studies, emotion-focused therapy, as a short-term therapy of 16 to 20 sessions, is listed as one of the empirically supported treatments for depression by the American Psychological Association (www.div12.org/PsychologicalTreatments/treatments/depression_emotion.html). It is also listed in a disorder-specific review of therapies in the category of level II evidence, indicating that in the research review including all studies published between 2004 and January 2010, there was at least one randomized control trial study that showed the effectiveness of emotion-focused therapy (Australian Psychological Society, 2010). In another recent meta-analysis of depression treatments, the authors came to the conclusion that “experiential therapy might be possibly efficacious with respect to both acute response and subsequent prevention” (Hollon & Ponniah, 2010, p. 916). Thus, the potential of emotion-focused therapy for depression treatment and prevention is recognized (Cooper et al., 2010; Greenberg & Goldman, 2018).

Emotion-focused therapy is also an evidence-based treatment for trauma therapy of men and women, which is a novelty as most trauma studies mostly refer to women (Paivio & Pascual-Leone, 2010). The application of emotion-focused therapy to other client groups, especially clients with eating disorders, has yielded promising results in pilot studies (Robinson et al., 2013, 2014).

Most of those aspects of therapy that are especially relevant for change in the client’s view are addressed in emotion-focused therapy. Looking back at 20 years of research on the client experience, Elliott (2008) states that the most important development is research that documents the client as an active change agent. Concepts like “the client as self-healer” (Bohart, 2004) and “self-agency” (Rennie, 2001) have been discussed and empirically studied using a variety of data collection and data analysis procedures. By asking former clients what they regard as a good outcome in psychotherapy, Binder et al. (2010) found four areas of change: better self-understanding and insight, self-acceptance, reduction of symptomatic distress/changes in behavioral patterns, and establishment of new ways of relating. Finally, various categorizations of client-perceived helpful aspects of therapy have been proposed. A meta-analysis based on seven studies examined the client-perceived impact of helpful events and found nine core categories: (a) awareness/insight/self-understanding, (b) behavioral change/problem solution, (c) empowerment, (d) relief, (e) exploring feelings/emotional experiencing, (f) feeling understood, (g) client involvement, (h) reassurance/support/safety, and (i) personal contact (Timulak, 2007).

In summary, the strength of emotion-focused therapy lies in its integrative nature and empirical validation. Its theory is based on neuroaffective evidence of the role of emotion in memory and thinking and how our identity is built. Moreover, its theory is based on evidence from psychotherapy process and outcome research that highlights emotional processes as an important common factor for therapeutic change. The marker-guided interventions are accessible for training, research, and supervision. Emotion-focused therapy theory is continuously being developed bottom-up and tested in practice.

Limitations

One limitation to the model is that there is little reference to existing concepts of emotional intelligence or other related concepts that might have the potential to inform emotion-focused practice. Although the client is seen as an active self-healer, the question remains as to who actually defines the emotional process, as most processing models are developed from an observer’s perspective.

Another limitation is that emotion-focused therapy is not suited to all clients. The ability to process emotion, which is a requirement for emotion-focused therapy, can be severely damaged due to specific mental disorders or being in an acute crisis. In acute psychosis or with suicidal ideation, for example, clients are not able to make use of their emotions as they are unable to feel and differentiate them. Clients with a diagnosis of social phobia, for example, have specific biases in their emotion recognition, which have been summarized as “rejection sensitivity.” These clients perceive more interactional cues for rejection—for example. in peoples’ facial expression when they interact with them—compared with healthy controls (Rosenbach & Renneberg, 2011). Moreover, clients have to have at least average intelligence to use two-chair dialog and alternate between various perspectives and aspects within themselves.

With regard to the emotional processing models that guide the interventions in emotion-focused therapy, there is no evidence to date that these are culturally or gender sensitive (Levant & Silverstein, 2006). Furthermore, the processing models can be criticized, because they “portray the client as a collection of processes that are operated on and changed by therapist interventions” (Bohart, 2004, p. 105):

Theoretically, from the “client as active self-healer” perspective, therapists’ empathic responses do not “operate on” clients’ experiencing levels or depth of processing independent of clients’ active agency and investment. Therapists’ empathy responses all by themselves do not promote clients’ self-exploration. Instead, it is clients who operate on therapists’ empathy responses to create these effects. (Bohart, 2004, p. 106)

For these reasons, there has been a longstanding debate whether emotion-focused therapy should still be part of the humanistic tradition.

CASE STUDY 13.1

Kate came to the psychosocial counseling service at the university where she had begun her studies. Her presenting problem was severe speech anxiety and procrastination. She had to give a presentation in one of her classes and felt paralyzed and unable to prepare for it. She was so worried about failing that she could not concentrate and reported feeling depressed and angry with herself. She had a number of somatic complaints such as sleeplessness, neck and back pain, and eating problems. She was on an antidepressant, a sleeping pill, and an anxiolytic as needed. Because of her anxieties, she was socially withdrawn and, as she had just moved to a new neighborhood, she did not have many friends. Kate was looking for help regarding her studies as she still procrastinated and felt depressed.

Kate presented with a state that in emotion-focused therapy is called “global distress,” where people experience a range of unpleasant emotions such as anger, stress, feelings of depression, and anxiety, and these emotions can either be directed at themselves or others. These emotions are often overwhelming. Kate, for example, would feel unable to do anything; she would sit for hours and go over fears and worries of what might happen. Eventually, she blamed herself for being a failure and for also letting down her parents, who financed her and her studies.

The first step for her was to become aware of her self-critical voice, which constantly blamed her and put her down. The self-critical process can be understood as the core process that triggers feelings of depression and anxiety. Therefore, it was important to heighten her awareness of this process as the generator of her depression and to strengthen her agency to change that process. In a chair dialog, she confronted herself with all the demands that she felt she should, ought, and must do to be a good student. It became clear that these demands she put on herself created a pressure on her that she would feel as a heavy weight, at which point she made a connection to her neck and back pain and her depressed mood. As the chair dialog brought out the underlying primary feelings behind her fear of failure—mainly a shame-based self-structure—she also made connections to where the shame would come from in her life and why it was difficult for her to feel lovable and worthy. She depended so much on constant positive feedback and success that the possibility of negative feedback or failure created pressure in her and made her unable to learn or fulfill any of the demands she put on herself. She also questioned her choices easily.

One of the most important emotional tasks for Kate was to develop the ability to self-soothe. Once she learned to self-soothe through positive images from her past and strong positive figures in her life, for example, an aunt whom she felt close to, her symptoms became less severe. She could connect to her inner representation of her aunt and recall an image of her and what she had said, and this would help her when she felt anxious and soothe her and give her hope. Kate learned to use these images when she felt overwhelmed by negative emotions. It was also important for her to experience the shame in the session in order to change it and let more resilient parts of herself become more visible and felt.

Finally, in the self-critical dialog, it became clear that some of the demands had a history that she traced back to unfinished business with her mother. She was the second daughter of a mother who had immigrated and wanted her daughters to have the success she could never find herself. Without being directly pushed, she had accepted unknowingly the emotional pressure from her family. Some of the criticism she generated in herself actually was support to help her make the best of a given situation and not let chances go by. Healing some of the unspoken in the internal dialogue as well as the imagined dialogue with the imagined mother helped her overcome her feelings of anxiety and depression, and she depended less on medication to control her emotions. For Kate, ccepting herself was also a journey of accepting her family’s background and history. Thus, emotional processing can also be understood in a systemic way.

Joy (2015) provides two case examples from the perspective of a social worker working in the context of the medical model in a hospital. Working in an emotion-focused manner here meant struggling with at least two roles—the role of the social worker resolving financial issues of the client and the role of an emotion-focused counselor, helping the client to understand and alleviate her emotional distress. Joy argues that even when the importance of emotion work is acknowledged, the frame that is set by a psychopathological medical model may make it more difficult to focus on emotion. Especially when working with clients with multiple losses, as is often the case in clients with a history of substance abuse, there is a need to acknowledge the pain and emotional distress that is associated with the loss of friends, family, or your own goals, perspectives, and dreams in life. Understanding and allowing the pain through empathic responses and time for listening will help clients to reconnect to their stronger parts within themselves, which may then lead to more self-confidence and empower clients to fight their symptoms and destructive behaviors. Connecting with the client and establishing the common goal between client and helper of an independent healthier life for the client can only be reached together and might only make sense for the client once a decision to change has been made. Marsha Linehan speaks of a decision for a new way with no self-harm and suicide attempts as a more general question that clients have to answer in order to keep focused on learning new skills and to remain hopeful that a new life is possible. Linehan is influenced by a Buddhist tradition as is a new approach merging meditation and mindfulness with emotion-focused therapy. Gaynor (2019) provides a case example using EFMT in a group format. In the case presented by Gaynor (2019), identifying and working with secondary anger and harsh self-criticism was essential in helping overcome depression and general anxiety disorder. These are interesting case examples that show how social work can integrate an emotion-focused approach and thereby be more effective in helping clients overcome their problems.

CONCLUSION

Emotion-focused therapy provides a framework for coaching clients to accept, regulate, and transform their emotions. This is relevant for many social work contexts, in counseling as well as other encounters with service users. Emotion-focused therapy guides the clients’ self-actualizing process by structured interventions that focus on emotions and create new emotion schemes. The integrative nature of emotions fits into social work’s person-in-environment view on mental health. Emotion-focused therapy theory and practice can help us develop emotional intelligence and competencies in our clients as well as ourselves. Being a reflexive practitioner entails therapeutic presence in the moment as well as a competent use of self in therapy and counseling. More research on emotion-focused therapy for specific groups of service users and various areas of social work practice is needed.

SUMMARY POINTS

•explored the theoretical underpinnings of emotion-focused therapy,

•explained the central tenets of emotion-focused therapy, and

•described the application of emotion-focused therapy to individuals and groups.